Long-term dependency outcomes in older adults following hepato-pancreato-biliary surgery for cancer
Bennett S, Chesney T, Coburn N, Zuk V, Haas B, Zhao H, Hsu A, Mahar A, Hallet J; REcovery after Surgical Therapy for Older adults Research – Cancer (RESTORE-Cancer) group. Ann Surg. 2021; Mar 22 [Epub ahead of print]. DOI: https://doi.org/10.1097/SLA.0000000000004867
Objective — To evaluate healthcare dependency following hepatopancreatobiliary (HPB) cancer surgery in older adults (OA).
Summary Background Data — Functional outcomes are central to decision-making by OA, but long-term risks of dependency have not been described beyond 1 year in this population.
Methods — All patients over age 70 undergoing hepatectomy or pancreatectomy for cancer between 2007–2017 in Ontario were analyzed. Outcomes were 1) receipt of homecare and 2) time at home. Homecare was analyzed with cumulative incidence functions, and time at home with Kaplan-Meier and Cox multivariate models.
Results — A total of 902 and 1283 patients underwent hepatectomy and pancreatectomy, respectively. Homecare use was highest (72.3%) in post-operative month-1, decreasing to stabilize between year-1 (25.5%) and year-5 (18.3%). Repeated receipt of homecare was associated with female sex (HR 1.18, 95%CI 1.05–1.32), receipt of adjuvant therapy (HR 1.56, 1.37–1.78), and more recent year of surgery (HR 3.80, 3.05–4.72). The ratio of home nursing care vs. personal support services reversed from 68%/26% in year-1, to 29/64% in year-5. High time at home (>350 days) at 1 and 5 years were 40.6% (95%CI 38.5%-42.6%) and 28.1% (25.9%-30.3%), respectively. The ratio of institution-days in acute care vs. nursing homes went from 77%/14% in year-1 to 23%/70% in year-5. Low time at home was associated with duodenal (HR 1.45, 1.15–1.70) and pancreas cancer (HR 1.20, 1.02–1.42), and with rural residence (HR 1.24, 1.04–1.48). High time at home was associated with more recent year of surgery (HR 0.84, 0.76–0.93) and perioperative cancer therapy (HR 0.88, 0.78–0.99). Increasing age was neither associated with homecare receipt nor time at home.
Conclusions — Following HPB cancer surgery, there is a high rate of long-term healthcare dependency for OA. There is an immediate high need for homecare that reaches a new baseline after 6 months, and the majority of OA will have at least one year with low time at home, most commonly the first year. These findings can aid in pre-operative preparation and transitional care planning.